Medical News: Looking back on the past year, how has the healthcare system changed and what is the physician community doing to adapt to the changing environment?

Fred Kinnicutt, MD: It seems almost impossible to keep up with the changing healthcare system. Each political party has its own agenda, which changes the expectations. Consequently, there is uncertainty about cost and coverage of healthcare for patients. Managed care organizations (MCOs) and health insurers seem to change what medical services, treatments and medications they will reimburse.

At the core, there is a lack of appreciation for medical knowledge. Physicians have to spend countless amounts of time and energy explaining why their patient needs a procedure, test or medication. I recently read that physicians spend two thirds of their time documenting. We use electronic medical/ health records that make us feel more like data entry specialists.

There’s a music video called EHR State of Mind, made by a group of physicians, Let Docs Be Docs, which says it best: The current electronic medical record is “just a glorified billing platform with some patient stuff tacked on.” The physician community is doing whatever we can to meet the needs of our patients. Some physicians are opting out of having to deal with MCOs and health insurers.

MN: As a behavioral health specialist, what is the impact of the opioid epidemic on the practice of medicine?

FK: As a child adolescent psychiatrist I have witnessed and seen the impact of the opioid epidemic on the practice of medicine. Our clinic is seeing more and more children who have experienced trauma and neglect because of their parents’ substance abuse. We are working with more adolescent patients who are falling into the darkness of opioid use. We have seen an increase in custodians and guardianship, which causes disruption in the child’s psychosocial development. The opioid epidemic has caused much trauma and death in many families. In a newspaper article last year, Kentucky’s child protective services (DCBS) reported that substance abuse by an adult is the number one killer (indirectly and directly) of children.

MN: How is the physician community working to address the opioid epidemic?

FK: The physician community is trying to address the opioid epidemic by supporting Kentucky laws, such as House Bill One, which regulate pain clinics and the prescription of pain medications. There are programs being promoted by different agencies, health organizations and academic centers which focus on treatment and prevention of substance abuse, especially opioids. Physicians are using these resources to screen, identify, treat and/or refer to drug treatment centers. The problem is that there are limited resources in each community.

Historically, physicians were told by the federal government to treat a patient’s pain; to not do so would involve severe ramifications. Consequently, pain pills were prescribed. Unfortunately, other modalities of pain treatment were not considered. Several physicians have told me that the MCOs will not pay for physical therapy or other forms of treating pain, but will pay for pain pills (which include opioids).

MN: How has the practice of medicine changed over your career? How would you like to see it continue to change?

FK: When I went to medical school I was told that I was currently learning would become obsolete sooner than I would believe. The many incredible scientific research discoveries since I attended med school make this statement true. Genetics plays a larger role in assessment and treatment of patients. We are seeing that the nature vs. nurture argument is well answered in epigenetics (environmental influences on the expression of genes).

The positive changes I have seen in medicine include involving the patient more in his/her care. There is a greater respect for the patient’s spiritual/religious beliefs than when I was in med school. This shows a truer desire to help and understand the entire patient.

Some of negative changes in medicine have included spending less time with the patient, not being able to interact with the patient face to face (doctor is typing away on the computer) and focusing on billing details instead of the art of medicine.

MN: What are the biggest challenges to practicing medicine in Kentucky? What are the benefits?

FK: The biggest challenges to practicing medicine in Kentucky include the opioid crisis, limited resources, increasing healthcare costs, ever changing governmental policies and expectations and health insurance companies (including MCOs) who do not easily approve treatment/testing/medication authorization requests.

Not long ago, our clinical nurse called a patient’s MCO for approval of a medication for a child. She explained that multiple medications were tried, and that the medication we were requesting was FDA approved for children. The MCO representative then asked, “What does FDA mean?” One of my patients, a 16-year-old girl with three psychiatric hospitalizations (for suicidal thoughts and gestures) and having legal issues did not get case management approval from her MCO. They felt she was fine.

The benefits of practicing medicine in Kentucky include working with some of the friendliest people I have ever met. Many patients and families are grateful for their care. Their rich life experiences have taught me much.

MN: What can Kentucky do to create a better environment for physicians?

FK: Kentucky should improve the standard of living for its citizens. Our state still has some of the worst poverty, obesity, tobacco use and substance abuse rates in the country. We need to continue to support and implement preventative education throughout the state. Policy makers need to be those who truly know healthcare (physicians, nurse practitioners, physician assistants, nurses and other healthcare providers). Ideally, healthcare organizations will and should have healthcare providers in leadership positions. The best healthcare organizations listen to and respect the clinicians and staff who are actually interact and work with patients and their families.